ModifiedUnitedHealthcarePolicy CS195KY.10

Treatment of Temporomandibular Joint Disorders (TMJ) — Kentucky

Kentucky-specific UnitedHealthcare medical policy describing coverage, medical necessity, and noncovered services for nonsurgical and surgical treatment of temporomandibular joint disorders for pediatric and adult members.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (TMJ) — Kentucky

Policy CodePolicy CS195KY.10

Change TypeRemoved specific unproven devicesclarified InterQual for pediatric surgery

Effective DateJun 1, 2026

Next Review Date

Key ActionUse InterQual clinical coverage criteria for prior authorization review of TMJ surgical procedures.

SourceLink

POLICY UPDATE CHANGES

Removed jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System, Jaw Dynasplint System) from the list of unproven and not medically necessary services.

Added language clarifying that TMJ surgical services referenced in InterQual criteria are proven and medically necessary for members under 18 in certain circumstances.

Removed CPT codes 21089 and 21499 from Applicable Codes.

Added language stating benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria.

18+ and <18Adult vs Pediatric

MultipleProven nonsurgical services

Multiple

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Unproven / Not medically necessary

InterQualInterQual referenced

NumerousCodes listed

Coverage and Medical Necessity Criteria

Coverage for Adult Members (18+)

Members 18 Years of Age and Older: Covered when criteria below apply

Proven nonsurgical services: Arthrocentesis OR Intra-articular corticosteroid injections OR Trigger point injections OR Physical therapy OR Occlusal splint (stabilization and repositioning splints)

Listed as proven and medically necessary nonsurgical services for adults.

Proven surgical services (in certain circumstances): Arthroplasty, TMJ OR Arthroscopy, TMJ OR Discectomy, TMJ OR Reconstruction, TMJ per InterQual clinical coverage criteria

Surgical services considered proven and medically necessary in certain circumstances; medical necessity clinical coverage criteria per InterQual.

Coverage for Pediatric Members (<18)

Members Under 18 Years of Age: Covered when criteria below apply

Proven nonsurgical services: Arthrocentesis OR Intra-articular corticosteroid injections OR Trigger point injections OR Physical therapy OR Occlusal splint (stabilization and repositioning splints)

Listed as proven and medically necessary nonsurgical services for pediatric members.

Proven surgical services (in certain circumstances): Arthroplasty, TMJ OR Other TMJ surgical procedures per InterQual Client Defined CP: Procedures, Arthroplasty, TMJ (Custom) - UHG

Surgical services considered proven and medically necessary in certain circumstances; medical necessity clinical coverage criteria per InterQual Client Defined - UHG.

Unproven / Not Medically Necessary

Services considered unproven and not medically necessary

Unproven therapies (adults): Biofeedback OR Multiple occlusal splints (e.g., daytime and nighttime, maxillary and mandibular) OR Epigenetic appliances (e.g., Homeoblock, DNA, Advanced Lightwire Functional appliance)

Listed as unproven and not medically necessary for adults due to insufficient evidence of efficacy.

Unproven therapies (pediatrics): Biofeedback OR Jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System, Jaw Dynasplint System) OR Multiple occlusal splints OR Epigenetic appliances

Listed as unproven and not medically necessary for pediatric members due to insufficient evidence of efficacy.

Evidence-based coverage implications

Evidence summaries and implied coverage-relevant conclusions

Arthroplasty for TMJ ankylosis: Evidence: Small RCTs and systematic reviews show similar long-term outcomes between gap arthroplasty and interpositional arthroplasty (dermis fat graft) with some short-term differences; higher recurrence reported after gap arthroplasty versus interpositional arthroplasty or reconstruction; autogenous interposition materials have lower recurrence than alloplastic materialssample size and follow-up limitations noted

Consider arthroplasty for ankylosis where indicated; choice of interposition material may affect recurrence (autogenous preferred)

Intra-articular corticosteroid injections and arthrocentesis: Evidence: Systematic reviews show corticosteroid injections and arthrocentesis (with Ringer's lactate) can reduce TMJ pain and improve maximum mouth opening (MMO) at 6–12 months; arthrocentesis plus injection may improve MMO more than injection alone; overall quality of evidence is low to very lowminimum follow-up 6 months in studies

May be considered for arthrogenous TMD when conservative therapy insufficient; superiority of injectables over lavage alone not established

Initial and Surgical Treatment Sequencing

Coverage approach and treatment sequencing

Conservative-first approach: Initiate treatment with conservative, reversible, evidence-based modalities (e.g., education, NSAIDs, soft diet, jaw rest, heat, physical therapy, occlusal splints) unless specific indications justify immediate invasive therapy

AADOCR and AAOMS recommend conservative care first; surgery reserved for patients with persistent moderate-to-severe pain or dysfunction after nonsurgical therapy; InterQual referenced for surgical medical necessity.

The policy identifies specific services that are considered unproven and not medically necessary for treatment of temporomandibular disorders. For adults the list includes biofeedback, multiple occlusal splints (for example daytime and nighttime or maxillary and mandibular splints), and epigenetic appliances (for example Homeoblock™, DNA® Daytime/Nighttime appliance, Advanced Lightwire Functional appliance). For pediatric members the policy lists the same services and explicitly includes jaw mobility mechanical stretching devices (for example TheraBite Jaw Motion Rehabilitation System®, Jaw Dynasplint® System) as unproven and not medically necessary due to insufficient evidence of efficacy.

Jaw mobility mechanical stretching devices are described as unproven because published studies are limited by small sample sizes, short follow‑up, high loss to follow‑up, inconsistent or unfavorable findings, and poor adherence. The policy notes that available trials do not establish an impact on clinical outcomes and that routine coverage is not supported without stronger evidence or compelling adherence documentation.

The policy states that a review of the medical literature did not identify quality evidence to support the efficacy of epigenetic appliances for TMJ disorders. Because effect on health outcomes cannot be established from the available literature, these appliances are considered not supported and therefore not medically necessary.

Listed examples of services characterized as unproven include: biofeedback; use of multiple occlusal splints (e.g., separate day/night or maxillary/mandibular appliances); epigenetic appliances such as Homeoblock™ and DNA®; and, for pediatric members, jaw mobility mechanical stretching devices (e.g., TheraBite®, Jaw Dynasplint®).

Interventions for which the policy found insufficient high‑quality evidence—specifically jaw mobility mechanical stretching devices and epigenetic appliances—are described as not supported by evidence for improved health outcomes. The policy therefore characterizes these devices as unproven and not medically necessary in routine practice absent compelling individualized documentation.

An operational revision effective 06/01/2026 updated the policy’s unproven/not medically necessary list by removing specified mechanical jaw‑stretching devices (for example, TheraBite Jaw Motion Rehabilitation System and Jaw Dynasplint System) from that list and by updating documentation and InterQual related language.

Procedure, Supply, and Product Codes

Trigger Point Injection CPT CodesCPTCovered

20552	Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553	Injection(s); single or multiple trigger point(s), 3 or more muscles

CPT Codes (procedures and modalities)CPT

20605	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
20606	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting
21010	Arthrotomy, temporomandibular joint
21050	Condylectomy, temporomandibular joint (separate procedure)
21060	Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
21070	Coronoidectomy (separate procedure)
21085	Impression and custom preparation; oral surgical splint
21110	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21240	Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
21242	Arthroplasty, temporomandibular joint, with allograft

1–10 of 18

1/2

HCPCS/DME CodesHCPCS

E0746	Electromyography (EMG), biofeedback device
E1399	Durable medical equipment, miscellaneous
E1700	Jaw motion rehabilitation system
E1701	Replacement cushions for jaw motion rehabilitation system, package of 6
E1702	Replacement measuring scales for jaw motion rehabilitation system, package of 200

Removed CPT CodesCPT

21089	CPT code removed from Applicable Codes
21499	CPT code removed from Applicable Codes

FDA Product Codes (informational)mixed

LZD	FDA product code for TMJ prostheses
MPI	FDA product code for TMJ prostheses
BXB	FDA product code for continuous passive motion machines

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required for TMJ Surgery

Prior authorization is required for TMJ surgical procedures. UnitedHealthcare uses InterQual® clinical criteria for medical necessity review of TMJ surgeries; refer to the InterQual Procedures criteria when requesting authorization.

Applies to arthroplasty, arthroscopy, discectomy, reconstruction, and related TMJ surgeries
Prior authorization review will reference InterQual® CP: Procedures criteria

Note

Use InterQual® for Medical Necessity Determinations

Coverage determinations are made using InterQual® as the primary medical/surgical criteria and must also align with applicable federal, state, or contractual benefit requirements. Documentation that meets InterQual® and benefit-rule requirements may be requested.

If InterQual® criteria are not applicable, UnitedHealthcare may use internal medical policies, coverage determination guidelines, or utilization review guidelines

Background and Scope

Temporomandibular disorders encompass a heterogeneous group of conditions affecting the temporomandibular joint and surrounding masticatory muscles. Patients commonly present with jaw pain, limited mouth opening (reduced maximum interincisal opening), and joint noises; symptoms may be acute and self‑limited or persist and cause functional impairment. Many cases respond to conservative, reversible therapies (for example NSAIDs, soft diet, jaw rest, heat, physical therapy, and occlusal splints), while persistent or refractory presentations may require targeted procedures such as arthrocentesis, injections, or, when indicated, surgical intervention.

Key Definitions and Procedural Terms

inv-30: Arthrocentesis — definition and procedural note

DefinitionArthrocentesis (lavage) is a minimally invasive procedure in which irrigants are injected into the temporomandibular joint space to remove inflammatory mediators or increase mobility by removing intra‑articular adhesions.

PurposeRemove inflammatory debris and break adhesions to improve joint mobility and reduce pain.

Procedural noteTypically performed by injecting lavage solution (e.g., Ringer's lactate) into the joint space; may be used as an early intervention when conservative measures fail.

inv-31: Occlusal splint — definition of oral appliance types and intent

DefinitionOcclusal splints are oral appliances (stabilization splints/night guards or mandibular repositioning splints) intended to reduce clenching or bruxism and to keep or reposition the jaw in a more relaxed position; may cover all or part of an arch.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (TMJ) — Kentucky

Policy CodePolicy CS195KY.10

Change TypeRemoved specific unproven devicesclarified InterQual for pediatric surgery

Effective DateJun 1, 2026

Next Review Date

Key ActionUse InterQual clinical coverage criteria for prior authorization review of TMJ surgical procedures.

SourceLink

On This Page

Trigger-point and needling therapies: Evidence: RCTs and network meta-analyses show trigger-point injections (local anesthetic), dry needling, platelet-rich plasma and other substances can reduce pain and improve MMO short- and intermediate-term, but evidence quality is loweffects often short- to intermediate-term

May be considered for myofascial TMD; heterogenous protocols limit definitive recommendations

Physical therapy and manual therapy: Evidence: RCTs and meta-analyses show physical therapy (including manual therapy, exercises, and multimodal PT) added to occlusal splints improves pain and MMO; exercise-alone may be equivalent to occlusal splints for MMO but not superior for painfollow-up commonly 3–6 months

PT is an effective component of multimodal management

Occlusal splints: Evidence: Network meta-analyses indicate stabilization splints and other occlusal devices provide short-term pain reduction and improved MMO; multimodal therapy (counseling plus hard stabilization splint) may yield maximal benefit; long-term differences often equalizeshort-term benefits more consistent than long-term

Occlusal splints remain a reasonable conservative therapy

Jaw mobility mechanical stretching devices: Evidence: Trials show no consistent superiority versus exercises, poor adherence, and inconclusive or unfavorable findings; devices considered unprovenadherence often low (e.g., reported low use rates)

Routine coverage not supported without stronger evidence or documentation of adherence

Epigenetic appliances: Evidence: No quality evidence identified to support efficacy; effect on health outcomes cannot be establishednone

Considered unproven

Benefit plan language controls if there is a conflict with standard policy guidance

Denial Risk

Documentation and Denial Risk

Medical record documentation must fully support the medical necessity for the requested services. Lack of adequate, legible documentation may result in denial of the requested service.

Documentation should include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures
Maintenance of legible records and prompt availability upon request is required
Insufficient or missing documentation does not guarantee coverage and may lead to denial

Documentation Required

Required Content of the Patient Medical Record

The patient's medical record must include detailed clinical information to support requests: history, physical exam, diagnostic test results, and prior conservative treatments. Records may be requested during prior authorization or claims review.

Include documentation of symptom history, pain severity, jaw range of motion, and functional impact
Include imaging and other diagnostic test results when applicable
Document prior treatments (NSAIDs, soft diet, jaw rest, moist heat, splints, physical therapy, injections) and responses

Note

Supportive Evidence Should Be Provided

Requests for services should cite and be supported by the clinical evidence summarized in this policy when applicable. InterQual® criteria incorporate current evidence; supporting trial and systematic review data may be requested to substantiate medical necessity.

Reference relevant RCTs and systematic reviews that support the requested intervention (eg, arthrocentesis, injections, physical therapy)
For interventions considered unproven (jaw mobility devices, epigenetic appliances), provide strong supporting evidence or expect denial

Prior Authorization

Conservative Care Required Prior to Invasive Therapy

Conservative, reversible therapies should be attempted before invasive procedures. Evidence and specialty guidance recommend initiating least-invasive, reversible treatments first.

Examples: NSAIDs, soft diet, jaw rest, moist heat, splints (occlusal), physical therapy, and targeted injections
Document trials of conservative care, duration, and clinical response prior to authorization requests for surgery

Note

Conservative-First Approach Supported by Evidence

Evidence supports a conservative-first approach: randomized trials and systematic reviews show benefit from arthrocentesis, injections, and physical therapy and recommend attempting these measures before surgery in many cases.

Minimally invasive procedures (arthrocentesis, intra-articular injections, arthroscopy) have demonstrated improvement in pain and mouth opening in multiple studies
Conservative-first approach should be documented and considered before approving surgical interventions

Prior Authorization

Attempt Conservative Therapy Before Surgery

Initiate and document the least invasive treatments first and attempt conservative therapies prior to considering surgery. Failure of adequate conservative management should be clearly recorded to support any subsequent surgical authorization.

Record specific conservative treatments tried, duration, adherence, and objective clinical response
For surgical consideration, include documentation of persistent moderate-to-severe pain or dysfunction despite conservative care

TypesStabilization splints (hard or soft), anterior repositioning splints, mini‑anterior splints, prefabricated and custom devices.

IntentUsed to treat myofascial pain dysfunction and TMDs, often as part of multimodal conservative therapy to reduce pain and improve mouth opening (MMO).

inv-32: Myofascial trigger points — definition and rationale for trigger point injections

DefinitionMyofascial trigger points are focal knots in a band of skeletal muscle caused by acute or repeated microtrauma commonly seen in TMJ disorders.

MechanismInjections or dry needling relax muscle fibers, allow lengthening of the muscle, and remove metabolite waste, breaking the pain–tension cycle.

Therapeutic rationaleTrigger point injections (with local anesthetic, saline, corticosteroid, or dextrose) or dry needling can reduce pain and improve function in myogenous TMD as part of multimodal care.

inv-33: Interpositional arthroplasty (IGA) — definition and when used (ankylosis)

DefinitionInterpositional arthroplasty (IGA) is a surgical procedure for TMJ ankylosis in which an interposition material (autogenous or alloplastic) is placed between joint surfaces after gap arthroplasty to reduce recurrence.

When usedIndicated for management of TMJ ankylosis where surgical intervention is required; choice of interposition material may affect recurrence (autogenous materials associated with lower recurrence).

Outcomes noteSystematic review data show IGA and reconstruction have comparable long‑term outcomes, with IGA often showing greater immediate improvement in MMO but study heterogeneity limits conclusions.

inv-34: Arthrocentesis (alternate entry) — joint lavage description and potential follow-up injections

DescriptionArthrocentesis is joint lavage (flushing) of the TMJ using solutions such as Ringer's lactate to remove inflammatory debris and extracellular matrix detritus.

Follow-up injectionsArthrocentesis may be followed by intra‑articular injections (e.g., corticosteroids or hyaluronic acid) which in studies have been associated with additional improvements in pain and mouth opening compared with lavage alone.

Clinical roleMay be considered a first‑step minimally invasive treatment for arthrogenous TMD when conservative therapy is insufficient; evidence supports improvement at 6–12 months but overall quality is low.

inv-35: Conservative, reversible, evidence-based therapeutic modalities — examples such as PT, occlusal splints, manual therapy

ExamplesPhysical therapy (exercises, manual therapy, multimodal PT), occlusal splints (stabilization or repositioning), and manual therapies (massage, hands‑on techniques).

PrincipleConservative, reversible, evidence‑based modalities should be tried first because many TMDs improve over time and these treatments pose less risk of irreversible harm.

AdjunctsBehavioral interventions (counseling), NSAIDs, soft diet, jaw rest, moist heat, and muscle relaxants often accompany these modalities as part of multimodal care.

inv-36: Surgical indication — surgery indicated when nonsurgical therapy ineffective and pain/dysfunction are moderate to severe

Indication for surgerySurgery is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe; not indicated for asymptomatic or minimally symptomatic patients.

Treatment sequencingInitiate the least invasive surgical or nonsurgical treatment first and attempt conservative, reversible therapies prior to surgical interventions when clinically appropriate.

Clinical workupOptimization includes thorough history, standardized exam, appropriate imaging, correct diagnosis, and individualized pretreatment therapeutic goals prior to considering surgery.